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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013418318
Report Date: 06/27/2022
Date Signed: 06/27/2022 01:31:42 PM

Document Has Been Signed on 06/27/2022 01:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:BARRAZA, CARLOS HFACILITY NUMBER:
013418318
ADMINISTRATOR:BARRAZA, CARLOS HFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 526-4357
CITY:BERKELEYSTATE: CAZIP CODE:
94707
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Carlos BarrazaTIME COMPLETED:
01:40 PM
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On June 27, 2022 at 11:24am Licensing Program Analyst (LPA) Indira Loza arrived at the facility to conduct an Annual Random inspection. LPA Loza met with Licensee Carlos Barraza. Present for the inspection were the Licensee, Licensee's Assistant, and 11 preschool children. The operating hours are Monday through Friday 8am-5:30pm.

The home is single story. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the living room/dining area (main day care area), bedroom (play area), hallway bathroom, and back yard. The kitchen/dining area is used as a walk through area to get to the back yard. The OFF LIMIT AREAS are the two hallway bedrooms, the basement, and shed that is located in the backyard which will be inaccessible by closed and/or locked doors and visual supervision. The ISOLATION AREA will be outside in a shaded area until the parent comes for pick up. The outdoor play area is free from defects or dangerous conditions and is completely fenced with 100% supervision. There are ample age appropriate toys that appear to be safe and in good condition. There is a covered jacuzzi in the backyard surrounded by a four foot fence, making it inaccessible to children. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.

LPA obtained the children’s files for review and the children's roster. Last Fire Drill was conducted April 6, 2022. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone, and fully stocked First Aid Kit. Licensee and assistants completed the Mandated Reporter Training which expires on June 19, 2024. Per licensee, there are no firearms in the home.

*****************************************Report Continues on LIC 809-C*******************************************
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: BARRAZA, CARLOS H
FACILITY NUMBER: 013418318
VISIT DATE: 06/27/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02 CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on
on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was issued Type B citation, see 809-D for details. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted, report and appeal rights were reviewed with Licensee Carlos Barraza.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
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Document Has Been Signed on 06/27/2022 01:31 PM - It Cannot Be Edited


Created By: Indira Loza On 06/27/2022 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: BARRAZA, CARLOS H
FACILITY NUMBER: 013418318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, as the Licensee and assistant did not have current CPR certifications, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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Licensee will enroll in a CPR course, and submit the certification by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022


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